Case Coordinator - RN / Case Coordination

Job Summary: The licensed Case Coordinator - RN demonstrates expertise in a healthcare setting in the assessment and treatment of patients along the continuum of care. This position develops and implements discharge planning within an interdisciplinary healthcare team and addresses complex clinical care needs by identifying and removing barriers that prevent optimum access to needed post-acute care. This position also collaborates with the providers to identify discharge barriers and delays in order to optimize the most efficient use of acute care hospital days and prevent prolonged length of stay. In addition, this position provides clinical leadership to their healthcare teams and ensures daily goals are being met according to the patient's plan of care.

Job Responsibilities: Assesses patient population in collaboration with the Health Care Team, for appropriate level of care across the care continuum; identifies risk factors such as clinical, psychosocial, and/or financial indicators and determines level of case coordination; facilitates involvement of support services to promote optimal clinical and financial outcomes. Develops and implements discharge planning in collaboration with the Health Care Team, by monitoring plans of care, coordinating consultations/referrals, identifying referrals for appropriate level of care, collaborating with patient and family and providing clinical information to community resources to provide efficient quality care. Collaborates daily with direct care providers to assess in-hospital stays and to facilitate post-hospitalization services, placement, and/or transportation. Models' quality patient/customer service by serving all customers at all times, maintaining and functioning in a collaborative manner with other caregivers to ensure quality patient care; maintaining awareness of patient/customer needs and responding to those needs; maintaining confidentiality of all patient information. Provides ongoing assessment, including gathering comprehensive information to use in developing interventions and treatment strategies. Optimizes client functioning through case management that facilitates collaboration among providers to address the client's biomedical and psychosocial needs to better provide efficient, appropriate, and beneficial health care services to a client with multiple needs. Advocates for the needs and interests of patients including advocating for larger system change to improve access to care and improved delivery of services. Educates patients, families, the community, and other professionals regarding disease prevention, impact of illness and disease progression, advocacy for benefits, health maintenance, and adherence to treatment regimens. Maintains timely documentation of case management services which reflect the patient and client systems' pertinent information for assessment, interventions, and outcomes. Provides timely assessments of needs for discharge planning for patients with prolonged length of stay. Identifies discharge delays throughout the hospitalization and develops countermeasures for potential barriers to discharge. Identifies lack of payer source and makes appropriate referrals to secure needed insurance coverage or providers for post-acute care needs. Identifies opportunities to decrease length of stay, reduce readmissions and improve patient experience through work in Lean huddles and participating in interdisciplinary team meetings. Assess patient's readiness for discharge based on patient's clinical status. Collaborates with providers to ensure appropriate patients are placed at appropriate level of care throughout their hospitalization and documentation supports patient's present level of care. Performs other related duties as required.

Licensure / Certification / Registration: Required Credential(s): Licensed Registered Nurse credentialed from the Connecticut Department of Public Health obtained prior to hire date or job transfer date. Preferred Credential(s): Certified BLS Provider credentialed from the American Heart Association (AHA). Certified BLS Provider credentialed from the American Red Cross. Case Management Certification preferred.

Education: Completion of a formal Nursing program. Associate's degree hires, Nursing Baccalaureate Degree (BSN) must be obtained within 6 years of hire. Work Experience: Three years of acute-care setting, diversified clinical nursing experience, including medical/surgical nursing. Case management, home care, and/or managed care experience are strongly considered. Previous experience in multiple healthcare settings (preferred). Knowledge, Skills, and Ability Requirements Demonstrate comprehension of medical terminology, natural history of illness and general disease processes; identification of and reliance on educational resources to continuously improve clinical practice as a medical social worker. Excellent communication, negotiation and conflict resolution skills required. Knowledge of computer applications preferred. Possesses ability to provide expert verbal and written clinical documentation and consultation along the continuum of care. Must be able to work collaboratively, efficiently, and effectively with multidisciplinary health care professionals to ensure a seamless transition of care for our patients and families. Ability to multi-task and address multiple needs of healthcare team members and patients/families. The ability to address complex psychosocial needs by collaborating with community resources and addressing barriers that prevent patients from optimizing their health and quality of life. Ability to work in fast changing healthcare environment. Must maintain CEU's as required for RN, CCM and/or ACM licensure. Preferred bilingual English/Spanish. Regular Standard Hours Per Week : 40 Schedule : Full-time (40 hours)

Shift Details: Monday to Friday, days, rotating weekends and holidays. Shift will vary based on needs of department